The Role of Bloodstain Pattern Analysis (BPA) in Reconstructing the Dynamics of Forensic Cases.

Background: Bloodstain Pattern Analysis (BPA) is a forensic scientific discipline used to resolve criminal events. By studying the size, shape, and distribution of the bloodstains that constitute one or more bloodstain patterns, it is possible to determine the physical events responsible for their creation, as well as the positions and movements of the victim and, in cases of homicide, the perpetrator during the act. Materials and Methods: BPA analysis was applied as a support in the reconstruction of the event dynamics in four forensic cases, in addition to the data collected during on-site inspections and instrumental investigations including PMCT, autopsies, histological, and toxicological analyses. Particularly laborious was its application in a case involving a decomposed body. In all cases, a thorough photographic analysis of the bloodstains found on the clothing worn as well as in the areas surrounding the location of the corpse was conducted. Conclusions: The combination of investigations, together with the data derived from the application of BPA, allowed events to be attributed to: homicide by blunt force trauma; homicide-suicide using a bladed weapon; homicide using firearms; unplanned complex suicide. The analysis of the cases presented highlights the importance of a multidisciplinary approach through the use of additional instrumental and specialist investigations such as the study of bloodstains present at the crime scene for the reconstruction of criminal events.

Use of morcellation in laparoscopic myomectomy. Medical malpractice and medicolegal considerations.

Background: In recent years, due to the increase in medical mal-practice complaints, the Sicilian Regional Health System has adopted procedures for the direct management of claims by each health facility with the aim of reducing the costs of insurance premiums and related taxes. Mandatory sentinel event monitoring is a crucial part of this strategy to improve patient safety and quality of care. The reported case relates to a laparoscopic myomectomy surgery performed by means of morcellation, a controversial technique. After the FDA's intervention in 2014, it is believed that morcellation may worsen the staging of the disease by spreading malignancies such as leiomyosarcoma into the abdomen. Case report: A 28-year-old woman, underwent laparoscopic surgery for uterine fibroids and an ovarian cyst removal in August 2018. Post-surgery, she was diagnosed with Leiomyoma. She returned to the hospital due to metrorrhagia and was discharged after a week. Persistent symptoms led to her readmission and subsequent exploratory laparoscopic surgery at another hospital. This resulted in a total hysterectomy and the discovery of uterine leiomyosarcoma, with FIGO STAGE IIIB staging. Despite chemotherapy, she passed away six months later. Discussion and Conclusions: This case highlights medical-legal issues. Informed consent for morcellation and its risks was not obtained. The morcellation technique was used, increasing cancer spread risk. The histopathological process was inadequate, with three biopsies leading to misdiagnosis. This could be medical malpractice, making providers legally responsible for the patient's deteriorating condition and the anticipation of possible death.

Case of tracheal rupture after endotracheal intubation: clinical risk management and medico-legal considerations.

Background: Tracheal injury may be a rare complication of the endotracheal intubation procedure. Incidence and determinant factors are not well known, nevertheless a greater incidence have been recognized with a difficult maneuver or the use of nitrogen peroxide. The therapeutic approach can be conservative or surgical, depending on the characteristics of the lesion and of the patient and therefore the outcomes of medico-legal interest can be different. Case description: It is a case of alleged medical liability regarding a 70-year-old woman, that during the intubation procedure was pouncing on the right. Furthermore, nitrous oxide was used as an anaesthetic. A few hours after the operation the patient showed swelling on the right half of the face and on the right lateral region of the neck. The emergency chest CT scan highlighted subcutaneous emphysema and pneumomediastinum. In the operating room, fibrobronchoscopy was performed with a double-lumen bronchial tube which confirmed the hypotheses lesion; then, right posterolateral thoracotomy was perfor-med followed by suturing of the tracheal lesion. Subsequently, the patient was discharged in good clinical conditions but with a scar in the region of the right hemithorax. Conclusions: Iatrogenic tracheal injury is a rare and fearful complication of the orotracheal intubation procedure. Although risk factors that increase the probability of its onset have been recognized, in most cases it is not possible to identify the cause. From a medico-legal point of view, tracheal injury after intubation is unpredictable and inevitable, so in the case reported it was decided to proceed with a conciliatory solution.

Homicide-Suicide and multidisciplinary approach: case series and a review of the literature.

Introduction: Despite being relatively rare in our country, murder-suicide phenomena have garnered increasing media attention over the years. However, actual data on their prevalence and characteristics remain limited. This study aims to describe and characterize all murder/suicide events reported at the Institute of Forensic Medicine in the Province of Messina, with a particular focus on distinguishing between cases of filicide/suicide and dyadic deaths. Materials and Methods: A retrospective observational analysis of judicial cases from 2018 to 2023 was conducted. Injuries were primarily localized to the head, neck, and chest for women, and to the head for men. In the case of filicides, death occurred through an asphyxiation mechanism, followed by the mother's suicide by hanging or falling. Conclusion: Within the scope of the medical examiner's activities, it is clear that acquiring more information through a standardized technical investigation and adopting a uniform approach could enhance the quality of the forensic service provided daily. This improvement, which would be in the interest of institutions and civil society, could be achieved through the sharing of procedures at both national and international levels.

Multiple suicidal gunshot wounds. Case reports and mini-review of literature.

Background: To determine the manner of death (MOD) and, there-fore, to classify the event as natural, suicidal, homicidal, or accidental is an essential and routine task in forensic medicine. The evaluation of MOD presents numerous difficulties due to unusual anamnestic and circumstantial data, in addition to autopsy findings and postmortem findings. Materials and Methods: A mini review of the literature on the topic was performed. Here we report two cases of uncommon self-inflicted multiple GWs (SMGWs) to the head and thorax, suspected of killing. The presence of more than one gunshot wound is suggestive of homi-cide, especially when they involve the head. A review of the literature on the topic was performed on PubMed's database, showing, although considered infrequent, cases documenting SMGWs are not rare. Conclusion: In the cases reported, the initial suspicion of involvement of third persons was excluded through the examination of the death scene, post-mortem (CT and autopsy) findings and clinical-circumstantial data. The analysis derived from the review of the related literature allowed us to highlight the presence of common findings which should be considered in the evaluation of such cases.

Homicidal or suicidal death? Evidence-based approach to assessing cause of death in a peculiar forensic case.

Background: In recent years, the improvement of common standards of forensic practice has received attention to promote an unambiguous and better-quality forensic investigation method. Although most hanging deaths are attributed to suicides, cases occasionally occur due to accidents or homicides. From an investigative point of view, hanging deaths are usually straightforward, but unusual circumstances may raise suspicions of crime. This includes complex suicides, which are rare events pursued by victims with two or more different fatal methods and can be classified as planned or unplanned, depends on whether the methods are applied simultaneously or sequentially. The multiplicity of injuries detected can often lead to misinterpretations, thus making a multidisciplinary approach extremely important. Case Report: A 44-year-old man, after requesting law enforcement, has been instead found inside a garden of an uninhabited property located a few kilometers away from his own property, suspended from a beam with wire; the wire created a noose at the back of his head, his hands were placed at his neck, and stab wounds were found. Conclusions: The crime scene investigation, interview of relatives, autopsy, histological and toxicological examinations, and GAP led to the determination that the death was suicide. This comprehensive approach emphasizes the importance of meticulous investigation and analysis to reach accurate conclusions in forensic cases.

Sudden Unexpected Death in Epilepsy (SUDEP). Full forensic approach in two cases and review of literature.

Background: The SUDEP is defined as a sudden unexpected death in patients affected by epilepsy, with or without evidence of a seizure, excluding documented status epilepticus, in which postmortem examination does not reveal a toxicologic or anatomic cause of death. Materials and Method: Here we report two cases observed at the Institute of Forensic Medicine of Messina, regarding the phenomenon, that were analyzed by a multidisciplinary approach. Meantime a systematic review of literature was performed using PubMed and Scopus databases. Conclusion: Although the mechanisms of SUDEP are not fully understood, several studies have allowed the identification of different brain areas whose anomalous stimulation, during epileptic seizures, could interfere with the correct control of cardiovascular and respiratory activities. The study highlights the importance of a complete multidisciplinary forensic approach analyzing different aspects in people affected by epilepsy, with no other cause of death. Furthermore, reinforce the definition of SUDEP for uniform cause-of death certification in these cases.

Analysis of the contentious relating to medical liability for healthcare-associated infections (HAI) in a Sicilian hospital.

Background: Since 2012, the Sicilian regional government, in view of the increase in malpractice claims, has adopted a "self-insurance system" The claims management activities have been delegated to the Claims Management Committees (CMCs), the importance of which was also emphasized by Law No. 24/2017. This study aims to describe the experience of Sicilian Hospital CMC and analyze the claims' features, especially for contentious HAIs. Healthcare-associated infections (HAIs) continue to be a major public health concern. The contraction of infection during hospitalization generally results in a significant worsening of the patient's quality of life and prolongation of his or her stay. Still, it is also responsible for an increase in costs that burden the hospital and the entire Health System. Material and Methods: The study investigates the analysis of claims received by a Messina Hospital Company between January 2015 and December 2023 even though for events that occurred in earlier years. From the database, cases in which the Company was sued for HAIs were extrapolated and analyzed, distinguishing them by year and by Department. The data collected were statistically processed with the Epi Info 7.1.5 program (CDC - Atlanta - USA). Conclusion: The CMC experience highlighted a statistically significant increase in complaints especially for those relating to HAI, without differences by Department. In most cases, the CMC admitted the hospital's liability, and an attempt at conciliation was promoted and moreover risk management initiatives were adopted. This is important when considering the recent ruling 6386/2023 of March 3, 2023.

The ghost dead: ethical and medico legal analysis on the Mediterranean tragedies.

Background: Cadaveric identification represents a legal, moral and medico-legal obligation and also fulfills the ethical function to allow the living to offer their dead a merciful burial. In the Mediterranean basin we have been witnessing for years a struggle for life where hundreds of migrants die in an attempt to reach Europe. For these people right to be recognized is not easy because of ante-death biological data are not always available for comparison, and DNA analysis is not always feasible cause for the absence of data with which to compare. In Italy a multidisciplinary protocol has been adopted that involves the acquisition of data provided by family members present in the countries of origin. Materials and Methods: Between August 2015 and December 2021, bodies of 879 migrants of various nationalities washed up on the shores of Sicily and Calabria. These men, women, and children, in various states of preservation, were examined. Each body underwent a multidisciplinary approach. External examination and autopsy aimed to determine the cause of death for judicial purposes and to facilitate individual identification. Whenever possible bodies underwent total body post-mortem computed tomography examination to identify fractures and prosthetic implants. including inspection of the third molar to provide an estimate of the age. Conclusions: The activity carried out in cooperation with Prefecture, Scientific Police, and National and International Red Cross highlighted the importance of employing multiple scientific skills to compensate for the lack of biological information. The importance of appropriate behaviors to avoid contamination and ensure proper preservation underlines the importance of the establishment of a dedicated database.